In one study announced at the Alzheimer's Association International Conference in Vancouver, British Columbia, this week, Mayo said it could detect symptoms of cognitive decline through closely studying people's walking stride.

A total of 1,341 healthy participants chosen from the Mayo Clinic Study on Aging were tested over the course of two years with an electronic, computerized instrument that picks up differences in a person's gait that even a well-trained physician can't recognize, said Dr. Rodolfo Savica, a Mayo neurologist.

Scientists studied stride length, speed and cadence. People who took shorter steps and walked more slowly "were having cognitive decline" over the course of the study, Savica said.

Memory, language, visual-spacial and executive function (or capacity to plan ahead) were reviewed. People who had a cognitive decline tended to have a decline in executive function. So it took them longer to, in essence, "plan" the next step.

The Mayo researchers believe a gait test could lead to earlier diagnosis, and if an Alzheimer's-delaying drug is developed, early diagnosis will be essential.

Keeping the brain active

In another new study, Mayo researchers suggest that varying mental activity through education and socialization can reduce the risk of dementia. Previous Mayo research suggested that computer use or exercise also help.

Mayo researchers examined 892 cognitively normal people taking part in the Mayo Clinic Study on Aging, creating an active map of their brains while the people were at rest.

Neurologist Dr. David T. Jones, lead author of an article on the brain mapping published in the journal PLoS One, said people have a fall-back brain pathway that they typically use while at risk. People with Alzheimer's tend to go back to that pathway more than people who are cognitively normal.

"Given that it looks like Alzheimer's disease targets specific networks, we need a good mapping of the way the normal brain forms these complex networks," Jones said.

The most striking feature of the brain map that tried to identify message centers in the brain, and pathways between them, was "it was dynamic. It continually changed throughout the scanning period, meaning that the pathways that regions of the brain use to communicate with each other, that was constantly changing."

Brains of people with Alzheimer's overused some paths and underused others.

Researchers used a field of study called "complex networks metrics." That research method looks at complex systems to understand how systems such as cities, social networks or airports are organized. The same concept is being applied to brain networks, Jones said.

People with Alzheimer's, or at risk for it, develop functional and metabolic changes in the brain-messaging network.

"We need to figure out why that's the case," Jones said. "So I wanted to figure out if Alzheimer's patients use the networks differently than people who didn't have Alzheimer's. And they do use it differently."

The next research step is to determine whether that's a cause or a consequence of the disease.

"These types of changes are present very, very early in the disease process," Jones said. In dominantly inherited Alzheimer's disease, changes in brain networks are present "even in 18-year-old subjects," he said.

Thus, Mayo researchers hope to expand the participation age for the Study on Aging to include younger participants. The study already includes people as young as 50.

Mayo scientists also presented evidence during the conference that new guidelines announced in April for Alzheimer's diagnosis work "quite well."

"It is very exciting because there have been some interesting findings and some interesting news," Savica said.

03/29/2012

Check out the Post-Bulletin newspaper on April 9 (2012). Until then, here are some suggestions from Olmsted County Public Health Lead Immunization Nurse Julie Gilkinson and Immunization Clinic Nurse Manager Linda Haeussinger for reliable sources of information about vaccination:

03/22/2012

A couple of weeks ago I wrote a Post-Bulletin column about a new uniform policy affecting about 900 clinical assistants and desk workers at Mayo Clinic here in Rochester, Minnesota.

Many clinical assistants called afterward. They nearly universally made a point of thanking the newspaper for writing about the topic — because they felt as if it's something they dare not speak about in the work environment.

As I mentioned in the column, Mayo, for years, has been cited as one of the best companies in the country to work for.

But clinical assistants were frustrated that, as some of the lowest-paid workers at the clinic, they're being asked to buy enough uniforms to meet their work needs.

They wanted in particular to make sure I clarified that the $400 repaid through payroll deduction is money they themselves have to pay. Mayo does not plan to give a clothing allowance as the workers switch from scrubs to a standardized uniform. Rather, the workers can get up to $400 worth of uniforms to replace their current work clothes and must pay that amount via payroll deduction (or credit card, immediate payment, etc.) over the course of 24 pay periods.

The workers expressed frustration that Mayo chose a Twin Cities uniform supplier that gets its uniforms from another country. In general, callers said they'd instead prefer to support local shops that sell uniforms.

They're also frustrated that the uniforms, they say, come in limited sizes and if their needs fall outside those sizes they must then get the uniform tailored every time they get a new one.

Clinical assistants wanted me to know that they perform a variety of tasks, in addition to the compassionate work of helping a patient in the rest room. They help with procedures, help with doctor communication and making sure patients get medication deliveries, as but limited examples of their varied duties.

They praised Mayo for encouraging education and certification, but were universally frustrated with Mayo's handling of the uniforms issue.

The calls continue to come.

Recently, callers have said that they're walking on proverbial eggshells because they're afraid to speak openly. There's also talk of organizing a union.

Seems when you make many among a group of 900 or so workers mad, there can be ripple effects.

No Mayo decision-makers or uniforms committee members have called to express Mayo's view. And perhaps they don't need to.

As I said in the column, the decision's been made. It's unlikely it will be changed (which might frustrate all those who have spent a couple of hundred dollars).

Clinical assistants have called to vent, reinforce that there's a communication problem and thank the Post-Bulletin for writing about the issue.

Seems to me, in my personal opinion, that someone failed to communicate very well.

Previously, I'm told, the problem with scrubs was that some supervisors were lax on enforcement of the dress policy. But a decision to switch to a standardized shirt-and-slacks policy might lead to the same problem, clinical assistants tell me.

Already, some supervisors say they won't enforce the new policy and will allow workers to buy their uniforms from places other than the approved out-of-town supplier.

Thus, the same problems as before will occur, clinical assistants tell me.

Only the future will demontrate the accuracy of that prediction.

Seems to me, in my personal opinion, that perhaps decision makers ought to gather around a table ask themselves where they went wrong, what they might have done differently and whether some of the employee concerns are valid.

One caller said it "breaks my heart that you're not free to speak about somthing as simple as a uniform."

Please keep in mind that companies often make business decisions that are unpopular. Right or wrong, front-line workers only get to make policy themselves when they become owners, supervisors or decision-making committee members themselves.

Still, when next the best-places-to-work survey occurs, this one chunk of the Mayo staff might have a tough pill to swallow if they're to rate their experience as highly as they once did.

03/21/2012

The Supreme Court of the United States has sided — unanimously — with Mayo Clinic in a case that has implications for health providers and patent law.

Here, in Mayo's own words released Tuesday (March 20, 2012), is the clinic's response to the Supreme Court decision:

ROCHESTER, Minn. — Today, the United States Supreme Court issued a unanimous decision in favor of Mayo Collaborative Services in a case against Prometheus Laboratories, Inc., that dates back to 2004. John Noseworthy, M.D., president & CEO, Mayo Clinic, issued the following statement in reaction to the decision:

"We are extremely pleased with the U.S. Supreme Court's decision. Mayo Clinic chose to pursue this lengthy litigation process because we believed it was in the best interests of our patients. This decision concerns the value of delivering high quality patient care in a timely manner and at an affordable cost.

"Essentially, everything we do at Mayo Clinic is about the needs of the patient and that's what this is all about. This is about everyday interactions between doctors and their patients."

At issue was a blood test developed by Prometheus that helps doctors decide the proper dosage for a drug called thiopurine, which is used to treat gastrointestinal illnesses. Mayo purchased this test until 2004, when Mayo researchers created an improved test. Prometheus sued for patent infringement and to block Mayo's use of its own test.

The decision allows other U.S. labs to offer a similar test, which will result in lower health-care costs for patients.

The Supreme Court said the Prometheus test wasn't eligible for patent because it "incorporates laws of nature.," according to the SCOTUS Blog.

"Giving doctors and medical researchers wider freedom to diagnose how patients react to drugs and other treatment options, without having to consult a patent lawyer, the Supreme Court on Tuesday unanimously struck down a Canadian company’s patents claiming an exclusive right to control the use of a method for determining the right dosage level of a specific class of drugs to give to a patient," says the SCOTUS Blog, which is sponsored by Bloomberg Law. "Finally moving to resolve an issue it has studied off and on for most of a decade, the Court sharply restricted the government’s power to issue patents to those who claim a new way to apply the laws of nature — including the physical reactions of the human body to medicines."

The Care Network is made up of health systems that can tout their affiliation with Mayo Clinic. In exchange for federally required payments, Network members get access to Mayo medical protocols, consultations and an expert phone line that connects them with rapid answers to medical quandaries.

According to its homepage, the Care Network "recognizes that people prefer to get their health care close to home. The main goal of the network is to help people gain the benefits of Mayo Clinic expertise without having to travel to a Mayo Clinic facility."

It's part of the clinic's goal of spreading the "Mayo model of care" nationally and even internationally.

01/18/2012

Mayo Clinic oncologist Dr. Axel Grothey says an investigational drug called regorafenib, taken when all other options fail, can slow metastatic colorectal cancer tumor progression and adds, on average, 1.5 months of life.

01/09/2012

The New York Times recently published an opinion piece by two physicians, one an oncologist and one a general internist, who decry Mayo Clinic's current cancer proton-therapy construction projects. One each in Arizona and Rochester, Minnesota will cost $180 million apiece.

Dr. Robert Foote, who is at the forefront of Mayo Clinic's proton therapy development, said neither Dr. Ezekiel J. Emanuel of the University of Pennsylvania nor Dr. Steven D. Pearson of Massachusetts General Hospital called him to ask about Mayo's motivation.

According to their opinion piece, "if you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives."

To read the opinion piece in full, click here (http://opinionator.blogs.nytimes.com/2012/01/02/it-costs-more-but-is-it-worth-more/).

Reactions to the controversial piece were varied, with a mix of pointed criticism and head-nodding agreement (particularly about the need for a different type of Medicare reimbursement).

Both the University of Pennsylvania and Massachusetts General said their physicians were expressing their own opinions, not speaking on behalf of the institutions.

Both Penn. and Mass. General have proton therapy centers. Mass. Geneneral's proton center director was not available, a public relations spokeswoman said.

Mayo's CEO, Dr. John Noseworthy, wrote to the Times, saying, "Mayo Clinic is resolute in its commitment to advance new, superior treatments that best serve patients based on clinical evidence. Our intent is not profit, nor is it to contribute to the medical arms race. In fact, we chose not to build a proton beam center on our Florida campus. That area was served by another center."

Jeff Bauer, a Chicago health futurist and medical economist with "40+ years of full-time experience in health care, including 17 years as a professor at two state medical schools, 4 years as health policy advisor to Colorado Governor Richard D. Lamm, and 20 years as a consultant and writer" had the following written responses to a Post-Bulletin inquiry:

• Enough evide to support construction of proton centers? The authors' argument is internally inconsistent. On the one hand, they want to deny payment for proton beam therapy due to a lack of research on its effectiveness. On the other hand, they criticize one of the world's best research institutions for wanting to acquire equipment to conduct the needed studies. I would put Mayo at or near the top of the list of health care systems that ought to have a therapeutic proton beam accelerator because it is a world-class research organization.

• How proton technology fits in context with MRI, CTs, etc.: I was serving as Health Policy Advisor to Colorado Governor Richard D. Lamm when CT and MRI were in the early stages of development for clinical applications (i.e., where proton beam therapy is today). Like Drs. Emanuel and Pearson, he initially argued that government policies were needed to prevent excessive spending on new, unproven technologies. I think I helped Gov. Lamm see the value of good research to develop both technologies and expect that he would now be glad he did not forever push a political position comparable to the one published in the Sunday Times. CT and MRI have been among the most beneficial medical technologies ever developed, more than justifying the costs of research and development. The issue of the cost of the proton beam procedure, the $50,000 fee that Medicare will presumably pay for the procedure, is a completely different economic issue from the cost of R&D, and I share Drs. Emanuel's and Pearson's concern with the per-procedure charge (see below). I've long argued that indefensible fees are charged for fully-defensible technologies. Many medical procedures cost way too much because the technologies are used inefficiently, not because the technologies themselves are too expensive. For example, CT and MRI tests would cost a whole lot less if hospitals used the machines more intensively. A typical 500 bed hospital in the US would have three CT scanners and 2 MRIs that are basically operated from 8 to 5; one of each device could provide just as many tests at a much lower cost if it were operated at least 16+ hours a day, as is the case in some very good 500 bed European hospitals. The high costs of many health care procedures in the US result from poor utilization, not the expense of the device needed to perform them, as shown by the history of CT and MRI. The $50,000 Medicare reimbursement is a red herring.

• Mayo Clinic plans to enter all its patients into research studies. Is that a reasonable answer to critics (who say there's not enough evidence proving proton therapy works better)? It is not only a reasonable answer; it is an essential answer, and I am glad that Mayo will be among the institutions able to conduct the research. Contrary to the implication of the article's statement that there is not a single randomized trial -- the implication being that we only need one center to conduct the research (i.e., sorry Mayo, the door is closed) -- we need several competent research organizations to be pursuing the technology because several research studies are needed to support any conclusions. Given my background in medical research and statistics, I would not be convinced that proton beam therapy was beneficial on the basis of a single randomized trial, the "gold standard" that is missing according to Drs. Emanual and Pearson. In other words, I strongly support Mayo being involved in proton beam research so that we can gather enough evidence to learn if it ought to be offered to any patient, regardless of its price.

• What should average Americans consider when reading about such topics? I think my answer to the previous question raises a few issues that average Americans should consider (e.g., R&D costs and charges are very important but different issues that ought not to be confused, need for many good research studies to decide whether the procedure has clinical merit independent of its costs). I also think that typical Americans ought to care more about the totally idiotic way that Medicare pays for care on a fee-for-service basis. To me, the issue is not whether Medicare can afford another provider charging $50,000 for proton beam therapy, but why Medicare is paying $50,000 to any provider in the first place. The way the Medicare sets its fees should be added to the list of things nobody would ever want to watch, which so far includes making sausage and passing laws.

• Assessment of Medicare concerns raised by the opinion piece: I wholeheartedly agree with their defense of dynamic pricing and other market mechanisms that would prevent insurance from paying more than the least-cost approach to produce a given outcome. If proton beam therapy ultimately turns out to be no better than other therapies for a given disease, then no insurance plan should pay more for proton beam therapy (assuming that an economically defensible price is being paid for the least-cost, clinically acceptable alternative). If the patient wants to pay the difference, that's OK by me, but I do not want to be paying higher insurance premiums for overpriced reimbursement. On the other hand, proton beam therapy could ultimately justify a relatively higher reimbursement (but probably not $50,000) if it is demonstrably superior to other therapies for a given condition.

• Other things to mention: I wish the authors had directly addressed the implicit issue of rationing (the elephant in the room). ObamaCare, which was certainly based on a lot of input from Drs. Emanuel and Pearson, absolutely prevents Medicare from basing coverage decisions on the results of comparative-effectiveness research. Curiously, the authors promote dynamic pricing in the article (with my strong support), but they helped pass a law that makes it illegal for Medicare payment determinations to be based on economic factors (a part of the ACA that I strongly oppose). To Dr. Emanuel's credit, he has actually taken a very defensible position on this issue in some of his other articles, but I think there's a lapse of consistency in this one. In my opinion, we will not halt the rising prices of health care procedures (a different issue than total expenditures on health care) until we develop a national policy that rations care on the basis of costs and benefits. The authors may be making this point in their last paragraph where they condemn the "no questions asked" basis of current Medicare reimbursement, but I sure would like to see a strongeer statement about the need to have a public debate about rationing because it's a precondition for creating efficient and effective health care.

Here is a summary of responses from Dr. Andrew Lee, director of the MD Anderson Proton Therapy Center in Houston, Texas:

• "Some of the stuff in there's factual. Some of it's maybe an exageration. Some of it's maybe not so factual."

• "It's an opinion piece. It's not meant to be a peer-reviewed article."

• "Everyone's entitled to an opinion."

• "It's meant to be thought-provoking and provocative. It does mean that it's true."

Do medical centers with proton therapy compete, or collaborate?

• "I would submit to you that there's almost no current operational proton center that's in operation, or that's being built, where someone from one of those entities has either not come to MD Anderson to actually visit the center and/or spent some time training here and/or have attended one of the conferences that we've provided." Mayo Clinic staff have been to MD Anderson several times for training.

• Loma Linda, Massachusetts General and Indiana have proton therapy.

• "We don't need to compete with those three centers. that was not our motivation."

Is there enough demand for proton therapy?

• "Even if there's 20 proton centers operating full blast in the US's, we're maybe going to address 4 to 5 percent of the radiotherapy population, if that."

• "Even our center, which is pretty big, we probably only can treat 1,200 pts a year."

Research:

• "We're also trying to study it to see how we can make things better. That's what top-flight institutions should be doing."

Medicare:

• The authors argue Medicare pays $50,000 for proton therapy, twice the cost of X-ray radiation. But IMRT is the type of conventional radiation therapy used most often, which is much more costly than X-ray.

• "This is misleading."

And a summary of responses from Dr. Foote of Mayo Clinic:

Competition or collaboration?

• "There's not competition. I think if you talk to the academic medical centers that have proton beam therapy, they'd all say that the enemy is cancer and we're all trying to work together to fight this common enemy and help each other develop more-effective and safer treatments."

• "I think they'd all say that the enemy is cancer and that we're all trying to work together to fight the enemy."

• We've done a lot of work with our colleagues at MD Anderson Cancer Center. Their facility is the closest to what ours will be like, as far as the same equipment vendor. And so our physicists and dosimitrists have spent, and will continue to spend, time there at MD Anderson getting training on the treatment planning and treatment delivery process — and they're not charging us any money for this. It's a consumption of their resources. It has a negative impact on their efficiency when you have people there standing around asking questions and slowing down the workflow."

• Mayo Clinic also plans to host staff from other health organizations once its own proton centers open.

Evidence about whether proton therapy works better than conventional radiation:

• "Our goal is to have every patient that we treat with proton beam therapy on a clinical trial, and we will be collecting, prospectively, outcomes data on all the patients. They're all registered on a patient registry where we study them into the future as long as they live."

• Data collected will include:

+ how long do they live?

+ how often do they experience recurrences?

+ what kind of side effects and complications do they develop — and how severe are they?

• That data will be compared to published national benchmarks for people treated with conventional radiation. It could take 10 to 20 years to get long-term results because it takes that long to start seeing long-term complications. Data comparing conventional complications such as nausea, vomiting, diarrhea, burned skin, dry mouth, altered taste, and problems of the bowel and of the bladder should be available quickly.

• "What kind of a monetary value do you put on that and what's that worth?"

• Is medical evidence lacking that proton therapy is unproven? "I think you can make a reasonable argument that's not true." Loma Linda Medical Center has published results on more than 1,000 prostate cancer patients, with long-term followup. Massachusetts General has published results on about 2,000 to 3,000 patients with melanoma of the eye. Mass. General and MD Anderson have published results on hundreds of patients with prostate cancer.

What happens if studies show proton therapy is not as effective as conventional therapy? "Then we go with the standard therapies rather than the proton-beam treatments."

Cost:

• The opinion piece focused on initial costs of proton therapy versus initial costs of conventional radiation. But costs such as effects on quality-of-life, time invested, number of trips to the medical center, travel time, lost work time and housing should be considered too.

• "There's more recurrences with X-rays and more long-term side effects with X-rays than with protons."

• Swedish studies showed that "the net analysis in the long-term over time is that the proton initial treatment ends up being less expensive, being the cheaper way to go, looking over the course of the patient's lifetime, by quite a bit."

• "Right now we are reimbursed by the number of treatments we give. The more treatments we give, the more revenue we generate. It's not unusual to have 30, 40, 45 treatments. If we can decrease that down to five treatments, then that's a huge savings. You've reduced the cost to Medicare, to the private insurer, by a lot. And we're very interested in doing that. Mayo wants to be affordable and have the least-expensive care possible.

On proton therapy:

• "I think over the years we'll discover that proton works very well for certain group of patients and diseases and it's not any better in other areas. That's part of the whole process."

• "Our facility is designed for kids. There's a special separate watiting room for the kids. There's a play area for the kids."

• Kids will make up about 10 percent of estimated 1,240 patients per year that will get seen for proton therapy in Rochester and the 1,240 that will get seen at Mayo in Arizona.

• "Our facility is geared toward children and we want to treat as many children as we can."

What types of adult patients will be seen at Mayo's Rochester proton center?

• Patients with melanomas of the eye, bone and soft tissue sarcomas involving the base of skull or spine and pelvic area, patients with lung cancer and esophageal cancer, and some women with breast cancer (if it's close to heart or lungs where damage can be spared to those organs. Also, men with lethal prostate cancer that needs to be treated.

• "We are interested in developing a less-expensive treatment with patients, seeing if we can give just 5 treatments instead of the typical 40 or 45."

12/09/2011

Be sure to read today's print edition of the Post-Bulletin. It'll be a different kind of gift because you'll be able to find a place to volunteer, an organization you can donate to and lots of gift-giving ideas for the holidays.

If you want to do some holiday giving to people in need, you'll be able to clip-and-save a list of area non-profits and their holiday wish lists.

The needs are as basic as sockes for women and children at the Women's Shelter to as specific as individual gifts for aging adults with disabilities at Bear Creek Services who have no family.

Years ago I dropped off a college mate at Thanksgiving time. He invited me inside to meet his mother. She'd made a special holiday meal. It consisted of moistened bread in a saucepan stirred with whatever spices she had.

That would be their entire Thanksgiving meal.

It meant a lot to him that she'd gone to all the trouble.

I wondered as I drove away what they would live off for the next three days while I was on holiday and they shared time together before I went back to pick him up. At the appointed time, I did so. And he was standing outside waiting, as had been the plan.

For many people, it's difficult to ask for help during rough times. When your child is sick and you end up at Ronald McDonald House, it can literally mean the difference between financial ruin and scraping by. Or, if you're a foster child and get kicked out of the house on your 18th birthday, the LINK Program can help you gain your footing.

If you're an adult with disabilities and want supported independence, Bear Creek Services can help. If you've been attacked by a violent abuser, the Women's Shelter can help (507-285-1010).

If you've ever used the Ronald McDonald House, the LINK Program at the Rochester Area Family Y, the Salvation Army or Legal Assistance, perhaps you'll find a gift to give on behalf of one of your loved ones. Zumbro Valley Mental Health offers services for homeless individuals. Unless you've lived on the street or in your car, it's tough to imagine what it's really like in a Minnesota winter — or to ask for help from the Dorothy Day Hospitality House homeless shelter here, or the Interfaith Hospitality Network. But such organizations are here to help.

The Salvation Army says 6001 hours of red-kettle bell ringing are expected to be donated by area volunteers this year (2011). Salvation Army funds the Good Samaritan medical and dental clinic here in Rochester, Minnesota, for example. For families and individuals without financial resources, the clinics can be a godsend.

If you're unable to help out financially, maybe you'll want to donate some of your time by volunteering. You can call and ask for volunteer opportunities at various non-profits by dialing 2-1-1 on any landline telephone in Minnesota ( on cell phones 800-543-7709; TTY 1-800-861-7364).

If you're interested in Salvation Army Red Kettle bell ringing in particular, you can sign up at www.RegisterToRing.com or call 288-3663.

Salvation Army volunteers are trying to raise $330,000. So far, they've raised just over $132,000, with just 11 bell-ringing days left.

12/05/2011

In town for a medical checkup? Got loved ones in town for the holidays?

Here's something for you to do that can be fun, entertaining and something to get everyone out of the house for a while.

Check out the winter Rochester Downtown Farmers Market at the Olmsted County Fairgrounds. Head south on Broadway (which is also called highway 63) with downtown behind you and the giant ear of corn water tower in front of you.

Turn left on 16th Street S.E., four blocks south of the giant ear of corn. There, you'll find the farmers market at the fairgrounds on your left.

Time: 9 a.m. to 12 noon

Date: Saturday December 10 (and December 17)

Location: Corner of 16th Street S.E. and Broadway

You never know what you'll find at the farmers market, winter included. My favorite is bags of dehydrated vegetables that you can take home and make into soup. Yum!